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Summary The IHDT has set an aggressive agenda for implementation of the IHS system. It is to be accomplished by the end of 1998. The success of setting the agenda was remarkable. However, it should be noted that the IHDT was a homogenous group, sharing similar values. If the implementation portion of this restructuring plan remains true to the intent (allowing each local service unit to be the decision maker), then the homogeneity of each group will be an asset. However, the fact that the IHS delivery system cannot exist as a self-contained isolated entity means that the number of players and decision-points to be addressed will make a two-year implementation plan difficult (Pressman & Wildavsky, 1984).

As challenging as this may be, there remains an optimism that the IHS will overcome these barriers. The future structure of the IHS may be very different than today as the I/T/U’s set out to redefine their function. In a recent communication to IHS staff, Dr. Trujillo foresees "a substantial increase in direct delivery of health services…by tribal health programs, and reciprocal decrease in the direct delivery of …services by IHS." (on-line, "Futures", 1997). He sees an evolvement of Tribal Health Maintenance Organizations on the horizon that will incorporate fee-paying non-Indian clients providing additional revenue. Trujillo expects a rise in activities such as health promotion and disease prevention. Another possible scenario is the development of a cabinet level Department of Indian Trust, which would bring together all Indian programs and allow for coordination with other departments and agencies. Block grants could be assigned to the Indian states. While Dr. Trujillo acknowledge these possibilities for change are on the table for discussion, he maintains this unwavering position. "The method of delivery of health care will change in the future Indian Health service, but the U.S. government’s commitment to providing health care for eligible American Indians and Alaska Natives will remain constant." (on-line, "Futures", 1997).